Good sleep and health
Authors: Baixin Chen, Alexandros N Vgontzas, Yun Li
Journal: The Lancet Healthy Longevity (2023)

Good sleep is of crucial importance to maintaining health and attaining longevity, whereas poor-quality or insufficient sleep can just as easily endanger health and shorten the human lifespan. In The Lancet Healthy Longevity, Ali T Siddiquee and colleagues1Siddiquee AT Lee SK Kim S Lee M-H Kim HJ Shin C All-cause and major-cause mortality associated with sleep latency in the Korean Genome and Epidemiology Study (KoGES): a population-based prospective cohort study.Lancet Healthy Longev. 2023; 4: e316-e325Google Scholar present the results of their population-based prospective cohort study of 3757 community-dwelling individuals in Ansan, South Korea, with a median follow-up of 16·7 years, and report that self-reported habitual prolonged sleep latency increased the risk of mortality in adults aged 40–69 years, providing further evidence of the importance of sleep for health maintenance. A self-reported habitual sleep onset latency of more than 60 min, based on the Pittsburgh Sleep Quality Index, was found to be associated with a significantly higher risk of all-cause (hazard ratio 2·22, 95% CI 1·38–3·57) and cancer-specific mortality (2·74, 1·29–5·82), although it was not associated with a higher risk of mortality due to cardiovascular disease. Insomnia is the most prevalent sleep disorder in the general population and in the clinical setting. Cohort studies have shown that individuals with insomnia complaints had a risk of developing hypertension that was 1·14–1·21 times higher than in individuals with no insomnia.2Li L Gan Y Zhou X et al.Insomnia and the risk of hypertension: a meta-analysis of prospective cohort studies.Sleep Med Rev. 2021; 56101403 Crossref PubMed Scopus (20) Google Scholar The risk of hypertension and other cardiometabolic problems increases substantially when objective sleep measures are included in the diagnosis of insomnia.3Li Y Vgontzas AN Fernandez-Mendoza J et al.Insomnia with physiological hyperarousal is associated with hypertension.Hypertension. 2015; 65: 644-650Crossref PubMed Scopus (46) Google Scholar, 4Dai Y Chen B Chen L Vgontzas AN Fernandez-Mendoza J Karataraki M Tang X Li Y Insomnia with objective short sleep duration is associated with hypertension.J Sleep Res. 2023; 27e13833 Google Scholar, 5Dai Y Chen B Chen L et al.Insomnia with objective, but not subjective, short sleep duration is associated with increased risk of incident hypertension: the Sleep Heart Health Study.J Clin Sleep Med. 2023; (published online April 20.)https://doi.org/10.5664/jcsm.10570Crossref Google Scholar, 6Vgontzas AN Liao D Pejovic S et al.Insomnia with short sleep duration and mortality: the Penn State cohort.Sleep. 2010; 33: 1159-1164Crossref PubMed Google Scholar, 7Vgontzas AN Fernandez-Mendoza J Liao D Bixler EO Insomnia with objective short sleep duration: the most biologically severe phenotype of the disorder.Sleep Med Rev. 2013; 17: 241-254Crossref PubMed Scopus (477) Google Scholar Although the diagnostic criteria for insomnia depend mainly on self-reported sleep symptoms, self-reported sleep variables (eg, sleep onset latency, wake time after sleep onset, and sleep duration) reflect not only sleep, but are also associated with physical (eg, pain and obesity) and mental health problems (eg, depression and emotional stress). For more than a decade, objective sleep measures (especially objective short sleep duration and prolonged latency assessed by the multiple sleep latency test) have been proposed as important measures for predicting the medical severity of insomnia. Several cross-sectional and longitudinal studies have shown that insomnia with an objective short sleep duration is associated with a 2–4 times increased risk of cardiometabolic comorbidity and mortality compared to normal sleepers with a normal sleep duration.3Li Y Vgontzas AN Fernandez-Mendoza J et al.Insomnia with physiological hyperarousal is associated with hypertension.Hypertension. 2015; 65: 644-650Crossref PubMed Scopus (46) Google Scholar, 4Dai Y Chen B Chen L Vgontzas AN Fernandez-Mendoza J Karataraki M Tang X Li Y Insomnia with objective short sleep duration is associated with hypertension.J Sleep Res. 2023; 27e13833 Google Scholar, 5Dai Y Chen B Chen L et al.Insomnia with objective, but not subjective, short sleep duration is associated with increased risk of incident hypertension: the Sleep Heart Health Study.J Clin Sleep Med. 2023; (published online April 20.)https://doi.org/10.5664/jcsm.10570Crossref Google Scholar, 6Vgontzas AN Liao D Pejovic S et al.Insomnia with short sleep duration and mortality: the Penn State cohort.Sleep. 2010; 33: 1159-1164Crossref PubMed Google Scholar, 7Vgontzas AN Fernandez-Mendoza J Liao D Bixler EO Insomnia with objective short sleep duration: the most biologically severe phenotype of the disorder.Sleep Med Rev. 2013; 17: 241-254Crossref PubMed Scopus (477) Google Scholar Furthermore, a study with a large clinical sample size showed that patients with insomnia who had prolonged sleep latency on the multiple sleep latency test had a 3–4 times greater odds of hypertension than normal sleepers with a short sleep latency.3Li Y Vgontzas AN Fernandez-Mendoza J et al.Insomnia with physiological hyperarousal is associated with hypertension.Hypertension. 2015; 65: 644-650Crossref PubMed Scopus (46) Google Scholar By contrast, no association was found between self-reported short sleep duration and cardiometabolic comorbidity and mortality in patients with insomnia.3Li Y Vgontzas AN Fernandez-Mendoza J et al.Insomnia with physiological hyperarousal is associated with hypertension.Hypertension. 2015; 65: 644-650Crossref PubMed Scopus (46) Google Scholar These findings suggest that insomnia with objective disturbance is a more severe phenotype than insomnia alone. In the study by Siddiquee and colleagues,1Siddiquee AT Lee SK Kim S Lee M-H Kim HJ Shin C All-cause and major-cause mortality associated with sleep latency in the Korean Genome and Epidemiology Study (KoGES): a population-based prospective cohort study.Lancet Healthy Longev. 2023; 4: e316-e325Google Scholar habitual prolonged sleep onset latency (ie, taking >60 min to fall asleep, more than once a week) was associated with an increased risk of all-cause mortality, which might reflect the chronicity and severity of the disorder. This finding is consistent with previous studies showing that the chronicity and severity of objectively measured insomnia (ie, insomnia with a short sleep duration) is linked to an increased risk of health problems and mortality.7Vgontzas AN Fernandez-Mendoza J Liao D Bixler EO Insomnia with objective short sleep duration: the most biologically severe phenotype of the disorder.Sleep Med Rev. 2013; 17: 241-254Crossref PubMed Scopus (477) Google Scholar However, in the present study, prolonged self-reported sleep onset latency was not associated with cardiovascular mortality, which might be partly due to the low number of cardiovascular deaths observed in this cohort: 42 (19%) of 226 deaths, compared with 94 (42%) deaths due to cancer (an unusual finding, considering that cardiovascular disease is generally the leading cause of death in most populations).8GBD 2019 Ageing CollaboratorsGlobal, regional, and national burden of diseases and injuries for adults 70 years and older: systematic analysis for the Global Burden of Disease 2019 Study.BMJ. 2022; 376e068208 Google Scholar Furthermore, a previous study showed that the association between self-reported sleep complaints and hypertension is much weaker than objective measures of sleep in patients with insomnia,4Dai Y Chen B Chen L Vgontzas AN Fernandez-Mendoza J Karataraki M Tang X Li Y Insomnia with objective short sleep duration is associated with hypertension.J Sleep Res. 2023; 27e13833 Google Scholar which might also explain the absence of association of self-reported sleep onset latency and cardiovascular mortality in the study by Siddiquee and colleagues.1Siddiquee AT Lee SK Kim S Lee M-H Kim HJ Shin C All-cause and major-cause mortality associated with sleep latency in the Korean Genome and Epidemiology Study (KoGES): a population-based prospective cohort study.Lancet Healthy Longev. 2023; 4: e316-e325Google Scholar Mechanisms underlying the relationship between insomnia, short sleep duration, and cardiovascular diseases are not yet fully understood. Sympathetic overactivation, systemic inflammation, and dysregulation of the hypothalamic–pituitary axis have been proposed as key pathological changes. Sympathetic activity is an integral part of cardiovascular homoeostasis, and sympathetic tone generally increases in daytime and decreases while sleeping. However, in the context of insufficient sleep, sympathetic activity might not return to normal levels at night-time. Moreover, multiple biomarkers of systemic inflammation (eg, C-reactive protein, TNFα, and interleukin-6), which are known to be part of the pathogenetic mechanisms leading to cancer, are increased in patients with short sleep duration or sleep disruption. The results of the study by Siddiquee and colleagues1Siddiquee AT Lee SK Kim S Lee M-H Kim HJ Shin C All-cause and major-cause mortality associated with sleep latency in the Korean Genome and Epidemiology Study (KoGES): a population-based prospective cohort study.Lancet Healthy Longev. 2023; 4: e316-e325Google Scholar further highlight that insomnia is a serious medical problem requiring an effective therapeutic approach. Findings from a preliminary single-centre study showed that trazodone, a widely prescribed sleeping drug in the USA, was more effective than cognitive behavioural therapy to treat insomnia with objective short sleep duration, resulting in increased objective sleep duration and slow-wave sleep and in decreased cortical hyperarousal and peripheral cortisol concentrations.9Vgontzas AN Puzino K Fernandez-Mendoza J Krishnamurthy VB Basta M Bixler EO Effects of trazodone versus cognitive behavioral therapy in the insomnia with short sleep duration phenotype: a preliminary study.J Clin Sleep Med. 2020; 16: 2009-2019Crossref PubMed Scopus (26) Google Scholar Furthermore, individuals with paradoxical insomnia, which is associated with normal sleep duration, might benefit more from cognitive behavioural therapy than those with non-paradoxical insomnia.10Sun Q Dai Y Chen B et al.The underestimation of sleep duration phenotype is associated with better treatment response to cognitive behavior therapy for insomnia in patients with chronic insomnia: a preliminary study.J Clin Sleep Med. 2022; 18: 2443-2450Crossref Scopus (1) Google Scholar In conclusion, good sleep, both subjective and objective, is essential for health. Adding objective short sleep duration to the investigation of subjective complaints of insomnia can help clinicians to reach a more precise diagnosis, prognosis, and treatment of the disorder. Future multisite, randomised, placebo-controlled trials with large sample sizes should be conducted to examine the efficacy of specific personalised treatments for different types of insomnia. We declare no competing interests. All-cause and major-cause mortality associated with sleep latency in the Korean Genome and Epidemiology Study (KoGES): a population-based prospective cohort studyIn this population-based prospective cohort study, habitual prolonged sleep latency was independently associated with an increased risk of all-cause and cancer-specific mortality in adults (independently of demographic characteristics, lifestyle factors, chronic morbidities, and other sleep variables). Although further studies are warranted to investigate the causality of the relationship, strategies or interventions to prevent habitual prolonged sleep latencies might enhance longevity in the general adult population. Full-Text PDF Open Access